Provider Demographics
NPI:1710001953
Name:CLUETT, SUSAN B (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:CLUETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:
Practice Address - Street 1:1204 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2824
Practice Address - Country:US
Practice Address - Phone:434-924-0123
Practice Address - Fax:434-243-3300
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024099811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007015U92Medicare ID - Type Unspecified
VAQ39847Medicare UPIN